4 Hospital Abstraction

The Jackson Heart Study: Annual Follow-up with Third Party Respondents

Attach 15-Hospital Abstraction (HRA) Form

The Jackson Heart Study: Annual Follow-up with Third Party Respondents

OMB: 0925-0491

Document [doc]
Download: doc | pdf

OMB # 0925-0491

Expiration Date.XX/XXXX




HOSPITAL ABSTRACTION FORM


ID NUMBER: FORM CODE: H R A VERSION: F DATE: 02/06/2007




LAST NAME: INITIALS:



INSTRUCTIONS: The Hospital Record Abstraction Form is completed for each eligible hospitalized event as determined by the Surveillance Event Eligibility Form, and for all eligible Cohort hospitalizations as determined by the Cohort Eligibility Form. Event ID, Name (or Soundex code) must be entered above. Refer to this form's Q by Q instructions for information on entering numerical responses. For multiple choice and "yes/no" questions, record the letter corresponding to the most appropriate response.



0.a. Hospital code number:


0.b. Medical Record Number:



0.c. Date of discharge (for nonfatal case) or death:

Month Day Year


17. What was the disposition of the patient on discharge?

Deceased D

Discharged alive A


18. Was an autopsy performed? .............. Yes Y

No N






19.a. Was the patient either dead

on arrival or did he/she

die in the emergency room? …….... Yes Y

No N

Go to Item 19e.



19.b. First recorded Systolic BP:

mmHg




If zero or not recorded, and patient died

within 24 hours, record 000 and go to

item 19e. If zero or not recorded and

patient lived at least 24 hours, enter 001.





19.c. First recorded Diastolic BP:

mmHg


d. First recorded Pulse Rate:

bpm


If pulse rate is greater than 0, go to Item 21d,

If 0 or not recorded, and patient

lived at least 24 hours, enter 001 and go to

Item 21d. If 0 or not recorded and

patient died within 24 hours, enter 000 and

continue with Item 19e.




e. Was there (an) acute episode(s)

of pain or discomfort anywhere

in the chest, left arm or

shoulder or jaw either just

before death or within 72 hours

of death? ....................... Yes Y


No N


Unknown U








19.f. Is there a history of myocardial

infarction prior to onset of

this event? ................…….…….... Yes Y

No N

Go to Item 19h.

Unknown U



g. Did a myocardial infarction

occur within four weeks of

this event? ..................... Yes Y


No N


Unknown U



h. Is there any history of

angina pectoris or coronary

insufficiency? .................. Yes Y


No N


Unknown U




19.i. Is there any history of

any other chronic ischemic

heart disease? .................. Yes Y


No N


Unknown U

Skip to Item 97, and treat as

as an out-of-hospital death.


20. Answer the following:


a. Do the Discharge Diagnoses

include any 410 or 411 codes? ... Yes Y

Go to Item 21a No N


b. *Item deleted*


c. *Item deleted*


d. Is there mention of acute

MI in the discharge summary? …. Yes Y

Go to Item 21a No N




20.e. The following apply to this chart:


1. Is this person a

cohort participant? ..........…………... Yes Y

No N


2. Is there more than one ECG? …. Yes Y

Go to Item 21a. No N

3. Is any Cardiac Enzyme

above the normal limit? .....…… Yes Y

Go to Item 21a. No N


4. Was there a transfer

(in or out)? ..................……………... Yes Y


No N

If all of Items 20.e.2 - 20.e.4 are

answered No, go to Item 97.

21. First recorded blood pressure

and pulse rate (not during CPR).


a. Systolic BP: ................

mmHg


b. Diastolic BP: ...............

mmHg


c. Pulse Rate: .................

bpm


d. Smoking Status: ............Current smoker C


Past smoker P


Smoker NOS S


Never smoker N


Unknown U


22. Has the Discharge Summary been transcribed or attached (include symptom onset, timing, hospital course, etc.)?

ID Label


Yes (Y)* or No (N)

[If Yes, specify on notelog]

23.a. Did acute cardiac symptoms begin

prior to arrival at this hospital?


Yes .................……………..... Y


No, after arrival .......………..…. N

No acute cardiac symptoms …. A

Unknown .................…………. U

Go to Item 24a.



23.b. Estimated time from onset of acute cardiac

symptoms to arrival at this hospital.


<1 hour ...............……….. A


>1 hour and <2 hours ...…. B


>2 hours and <4 hours ...… C


>4 hours and <6 hours ...…. D


>6 hours and <12 hours ..… E


>12 hours and <24 hours ..... F


>1 day and <3 days .....…... G


>3 days .................……….. H


Not recorded .........…….…. U

Go to Item 24b.

24.a. What was the primary diagnosis or

reason for admission to this hospital?


Elective cardiac

catheterization .........………. A

Elective coronary

bypass surgery ..........………. B


Other non-acute

CHD evaluation ..........…….. C


Cancer ...............……..……... D


Diabetes mellitus .........……. E


Stroke ..................………….. F


Chronic obstructive

pulmonary disease ........…… G


Peripheral vascular disease …. H


Gallbladder disease .....…..…. I


Other .....................…………. O


24.b. Was there mention of an acute CHD

event with onset after arrival

at this hospital? ................... Yes Y

Go to Item 25.a. No N



c. Date of in-hospital CHD event:


Month Day Year




[NOTE: If patient had both CHD event

present on admission (Item 23=Y) and

after admission (Item 24b=Y), you must

decide which event is more important

(see Instructions). Answer subsequent

questions for the more important event.]




25.a. Was there an acute episode(s)

of pain or discomfort anywhere

in the chest, left arm or

shoulder or jaw, either within

72 hours prior to arrival to

this hospital, or in conjunction

with the in-hospital CHD event

defined in Item 24b? ...……......... Yes Y


No N

Go to Item 26.a.

Unknown U


b. Date of onset of pain:


Month Day Year



25.c. Did this pain or

discomfort specifically

involve the chest? .............. Yes Y


No N


Unknown U



d. Was the discomfort or pain

diagnosed as having a

non-cardiac origin? ............. Yes Y


No N

Go to Item 25f.

Unknown U


e. If Yes, specify:


_______________________________________________



f. Did the patient die? ......…………...... Yes Y


No N

Go to Item 26.a.


25.g. Approximately how long was it from

the onset of this event to death?


<1 hour ............……….. A


>1 hour and <6 hours …. B


>6 hours and <24 hours … C


24 hrs or more ...…….…. D


Unknown ...........…….… U


26.a. Was coronary reperfusion

(coronary angioplasty, coronary

atherectomy, bypass, intravenous

or intracoronary thrombolysis)

attempted in the first 24 hours

after onset of this event? ..…….... Yes Y


No N

Go to Item 27.



26.b. Approximately how long was it between

event onset and attempt at reperfusion?

< 1 hour ...........……..... A


> 1 hour and <2 hours ... B


>2 hours and <4 hours ... C


>4 hours and <6 hours ... D


>6 hours and <8 hours ... E


>8 hours ....……............ F


Unknown ......……......... U


27. Was the patient ever in a

CCU/ICU or telemetry bed

during this hospitalization? ......Yes Y


No N

Unknown U


28. Were any of the following mentioned as

being present during this hospital stay?


a. Shock or cardiogenic shock

(pump failure) ..................……….. Yes Y

Go to Item 28b. No N

1. Did shock occur within

the first 24 hours after

onset of this event? ........ Yes Y


No N


Unknown U


b. Congestive heart failure

or pulmonary edema ..........…....... Yes Y

Go to Item 28c. No N


1. Did CHF or pulmonary edema

occur within the first

24 hours after onset of

this event? ...............….... Yes Y


No N


Unknown U


c. S3 Gallop (third heart sound) ....... Yes Y


No N



28.d. Rales (not just basilar) ............ Yes Y


No N



e. Ventricular fibrillation or

cardiac arrest or asystole ......... Yes Y

Go to Item 28f. No N


1. Did ventricular fibrillation

or cardiac arrest occur

within the first 24 hours

after onset of this event? ... Yes Y


No N


Unknown U



f. Pulmonary embolus ................... Yes Y


No N



g. Stroke ..........................……….. Yes Y


No N



h. Pneumonia ........................……. Yes Y


No N


29. Were the following special

procedures or operations

performed during this

hospital stay?


Yes No


a. Cardiac catheterization Y N


b. Coronary angiography Y N


c. Coronary angioplasty Y N

Go to Item 29c2.


29.c.1. Approximately how long after the

onset of this event was the

performance of the coronary

angioplasty?


Before onset .....……...... A

< 1 hour ............……...... B

> 1 hour and <2 hours .... C

>2 hours and <4 hours .... D

>4 hours and <6 hours .... E

>6 hours and <8 hours .... F

>8 hours and <24 hours ... G

>24 hours ............…….... H

Unknown ...........……..... U



29.c.2 Coronary atherectomy .........…...Yes Y

Go to Item 29.d.───────── No N

c.3. Approximately how long after the

onset of this event was the

performance of the coronary

atherectomy?


Before onset .........……..... A


< 1 hour ..............………… B


> 1 hour and <2 hours ..…. C


>2 hours and <4 hours ..…. D


>4 hours and <6 hours ..…. E


>6 hours and <8 hours ..…. F


>8 hours and <24 hours .…. G


>24 hours ............…….…. H


Unknown .............…...….. U




Yes No

29.d. Swan-Ganz catheterization Y N



e. Echocardiography Y N



f. Coronary bypass surgery Y N

Go to Item 29g.


f.1. Approximately how long after the onset

of this event was the performance

of the coronary bypass surgery?


Before onset ....……........ A


< 1 hour ..........………..... B


> 1 hour and <2 hours .... C


>2 hours and <4 hours .... D


>4 hours and <6 hours .... E


>6 hours and <8 hours .... F


>8 hours and <24 hours.. ... G


>24 hours ...........……..... H


Unknown ...........……..... U


29.g. Intracoronary streptokinase,

urokinase, anistreplase,

APSAC, or TPA reperfusion ......... Yes Y


No N



h. Intravenous streptokinase,

urokinase, anistreplase

APSAC, or TPA reperfusion ......... Yes Y


No N



If 29g and 29h were answered "No",

Go to Item 29i.

29.h.1. Approximately how long after the onset

of this event was the performance of the

intracoronary or intravenous reperfusion?


Before onset ........……..... A

< 1 hour ...............………. B

> 1 hour and <2 hours ...... C

>2 hours and <4 hours ..... D

>4 hours and <6 hours ..... E

>6 hours and <8 hours ..... F

>8 hours and <24 hours .... G

>24 hours .............…….... H

Unknown .............…….... U


Yes No


29.i. Aortic balloon pump Y N



j. Radionucleide scan of heart Y N

Go to Item 29m.


k. If yes, specify type:


_____________________________________________


l. *Item deleted*


m. MRI scan of heart Y N


n. Exercise stress test Y N



Yes No


29.o. Holter monitoring Y N


p. Pacemaker (temporary, wires) Y N


1. Coronary stent Y N

Go to Item 29p2.


a. Approximately how long after

the onset of this event was

the placement of the coronary

stent?


Before onset ..........…….. A

< 1 hour .............……….. B

> 1 hour and <2 hours ..... C

>2 hours and <4 hours ..... D

>4 hours and <6 hours ..... E

>6 hours and <8 hours ..... F

>8 hours and <24 hours .... G

>24 hours ..............…….... H

Unknown .................……. U


Yes No


29.p.2. Implanted defibrillator Y N

Go to Item 29p2c.

a. Approximately how long after the

onset of this event was the

defibrillator implanted?


Before onset .........…….... A

< 1 hour .............……….... B

> 1 hour and <2 hours ..…. C

>2 hours and <4 hours .….. D

>4 hours and <6 hours .…. E

>6 hours and <8 hours .…. F

>8 hours and <24 hours ... G

>24 hours ..........………... H

Unknown ...........……...... U

Yes No

29.p.2. c. Coronary CT Y N


d. MRI Stress Test Y N


29.q. Other (specify):

1._________________________________________________

_________________________________________________



2._________________________________________________


_________________________________________________




30a.. Was closed chest massage (CPR) and/or

cardioversion attempted within 24 hours

prior to arrival at this hospital or

anytime during this hospitalization? ..... Yes Y

No N

Go to Item 31.a.


b. Date of first onset of attempted

CPR and/or cardioversion:


Month Day Year



30.c. Where was first CPR and/or cardioversion started?


(Circle one)

Private residence ..….. R

Work ...............……... W

Public place .......……. P

Emergency vehicle .…. V

Emergency room ......…E

Hospital ...........……… H

Other ..............………. O

Not recorded .......…… U




31. Were any of the following drugs given during

this hospitalization or at discharge?


Yes No



a. Nitrates Y N


b. Calcium channel

blockers Y N


c. Beta-blockers Y N


d. Digitalis Y N


e. Lidocaine (xylocaine)

I.V. or I.M. only Y N


f. Coumadin (Warfarin,

Panwarfin, Dicumarol) Y N





Yes No



g. Aspirin - on regular

basis (not PRN) Y N



h. ACE or Angiotensin II inhibitors Y N



i. Intravenous heparin infusion Y N



j. Antiplatelet agents (non-aspirin) Y N


k. Glucose, insulin,

potassium infusion (GIK) Y N



l. Lipid lowering medications

(Statins, Niacin, Other) Y N






32. Is there a history of myocardial

infarction prior to the onset

of this event? .................………….. Yes Y


No N


Unknown U



[If U, also review previous discharge diagnoses.]



33. Is there any history of

angina pectoris or coronary

insufficiency? ..................……….. Yes Y


No N


Unknown U


If Item 32 or Item 33 is answered

"Yes", Go to Item 35.



34.a. Is there a history of any other

chronic ischemic heart disease? ..... Yes Y


No N

Go to Item 35.



b. Specify: _______________________________________




35. Is there a history of valvular

disease or cardiomyopathy? ..........…. Yes Y


No N



36. Is there a history of coronary

bypass surgery prior to this event? .… Yes Y


No N



37. Is there a history of coronary

angioplasty prior to this event? ...... Yes Y


No N




















38.a. Is there a history of hypertension

(high blood pressure) prior

to this event? ................…………. Yes Y


No N


Unknown U

b. Does this patient have diabetes

(high blood sugar), either

history or diagnosed this

hospitalization?..............……… Yes Y


No N


Unknown U


39. Is there a history of

stroke prior to this event? ..... Yes Y


No N

Go to Item 41.

Unknown U





40. Did a stroke occur within 4

weeks prior to this event? ........ Yes Y


No N


Unknown U

41. Were any cardiac enzymes

reported within days 1-4

after arrival at the hospital

or after in-hospital CHD event? ....... Yes Y


No N

Go to Item 43cc.



42.a. Is there mention of the

patient having either trauma,

a surgical procedure, or

rhabdomyolysis, within one week

prior to measurement of enzymes? .... Yes Y


No N

Go to Item 42d.

b. Indicate type of procedure or trauma: Yes No

1. Cardiac procedure………………… Y N

2. CPR or cardioversion…………….. Y N

3. Other cardiac trauma……………… Y N


4. Specify:____________________

5. Rhabdomyolysis…………………... Y N

6. Intramuscular injection……………. Y N

7. Non-cardiac procedure…………..... Y N

8. Specify:____________________

9. Non-cardiac trauma………………... Y N


42.c. Enter the item number from the biomarkers

section of this form corresponding

to the first biomarker measurement

performed after the trauma, cardiac

procedure or rhabdomyolysis:


d. Is there any evidence of

hemolytic disease during

the hospitalization? ..............…………. Yes Y


No N

B. BIOMARKERS

43. LABORATORY STANDARDS

Upper Limit Special**

Range Set 1 of Normal Units

Total CK (CPK) a.

CK-MB (hrt frac) b. . c.

.

Total LDH d.

LDH1 e . f.

.

LDH2 g. . h.

.

LDH1/LDH2 i. . j.

.

Troponin I u. . v.

.

Troponin T w. . x.

BNP (brain natriuretic peptide): cc. . pg/ml If Q41=N, then answer only Q43cc

and Q43dd. Then skip to Q56aa.

Serum Creatinine: dd. . . mg/dl

Pro- BNP: ee. . pg/ml

Upper Limit Special**

Range Set 2 of Normal Units

Total CK (CPK) k.

CK-MB (hrt frac) l. m.

Total LDH n.

LDH1 o. p.

LDH2 q. r.

LDH1/LDH2 s. t.

Troponin I y. z.

Troponin T aa. bb.

**Special Units:

CK-MB, Troponin I, Troponin T LDH1/LDH2

1 = (Negative/Positive) or (Absent/Present) or (Normal/Abnormal) 5 = %

2 = (Negative/Weak Positive/Positive) or (Absent/Trace/Present) 6 = Proportion (decimal)

or (Normal/High Normal/Abnormal) 7 = (Negative/Positive) or (LDH1 < LDH2 / LDH1 > LDH2)

CK-MB, LDH1, LDH2

3 = Expressed as % of total enzyme

4 = Expressed as proportion (decimal units) of total enzyme


BIOMARKERS: DAY ONE

b. Were enzyme measurements taken on this date?..... Yes Y

44.a. Date

No N

Month Day Year Go To Item 48.a.


Record values in chronologic order for the three highest reports for each enzyme on Day One of arrival or in-hospital

CHD event. (LDH1 and LDH2 must be on same specimen.)

Value (See Footnote next page)* Range Set

45. Total CK (CPK) a. b.

CK-MB (hrt frac) c. . d.

Total LDH e. f.

LDH1 g. . h.

LDH2 i. . j.

LDH1/LDH2 k. . l.

Troponin I m. . n.

Troponin T o. . p.

46. Total CK (CPK) a. b.

CK-MB (hrt frac) c. . d.

Total LDH e. f.

LDH1 g. . h.

LDH2 i. . j.

LDH1/LDH2 k. l.

Troponin I m. . n.

Troponin T o. . p.

47. Total CK (CPK) a. b.

CK-MB (hrt frac) c. . d.

Total LDH e. f.

LDH1 g. . h.

LDH2 i. . j.

LDH1/LDH2 k. . l.

Troponin I m. . n.

Troponin T o. . p.

BIOMARKERS: DAY TWO


b. Were enzyme measurements taken on this date? ........ Yes Y

48.a. Date

Month Day Year No N

Go to Item 51.a.

Record values in chronologic order for the two highest reports for each enzyme on Day Two following arrival or

in-hospital CHD event. (LDH1 and LDH2 must be on same specimen.)


Value* Range Set


49. Total CK (CPK) a. b.

CK-MB (hrt frac) c. . d.


Total LDH e. f.

LDH1 g. . h.


LDH2 i. . j.


LDH1/LDH2 k. . l.

Troponin I m. . n.

Troponin T o. . p.

Value* Range Set

50. Total CK (CPK) a. b.


CK-MB (hrt frac) c. . d.


Total LDH e. f.


LDH1 g. . h.


LDH2 i. . j.


LDH1/LDH2 k. . l.


Troponin I m. . n.


Troponin T o. . p.

*Special Values:

CK-MB, Troponin I, Troponin T

A = Negative or absent or normal

B = Weak positive or weak present or trace or high-normal or small

C = Present or positive or abnormal or medium or large

LDH1/LDH2

D = LDH1/LDH2 reported only as > upper limit or positive or LDH1 > LDH2 (or "flipped")

E = LDH1/LDH2 reported only as < upper limit or negative or LDH1 < LDH2 (or "non-flipped)


B IOMARKERS: DAY THREE


b. Were enzyme measurements taken on this date? ........ Yes Y

51.a. Date

Month Day Year No N

Go to Item 54.a.

Record values in chronologic order for the two highest reports for each enzyme on Day Three following arrival or

in-hospital CHD event. (LDH1 and LDH2 must be on same specimen.)


Value* Range Set


52. Total CK (CPK) a. b.


CK-MB (hrt frac) c. . d.


Total LDH e. f.


LDH1 g. . h.


LDH2 i. . . j.


LDH1/LDH2 k. . . l.


Troponin I m. . . n.


Troponin T o. . . p.


Value* Range Set


53. Total CK (CPK) a. b.


CK-MB (hrt frac) c. . d.


Total LDH e. f.


LDH1 g. . . h.


LDH2 i. . . j.


LDH1/LDH2 k. . . l.


Troponin I m. . . n.


Troponin T o. . . p.


*Special Values:

CK-MB, Troponin I, Troponin T

A = Negative or absent or normal

B = Weak positive or weak present or trace or high-normal or small

C = Present or positive or abnormal or medium or large

LDH1/LDH2

D = LDH1/LDH2 reported only as > upper limit or positive or LDH1 > LDH2 (or "flipped")

E = LDH1/LDH2 reported only as < upper limit or negative or LDH1 < LDH2 (or "non-flipped)


B IOMARKERS: DAY FOUR


b. Were enzyme measurements taken on this date? ........ Yes Y

54.a. Date

Month Day Year No N

Go to Item 56aa.

Record values in chronologic order for the two highest reports for each enzyme on Day Four following arrival or

in-hospital CHD event. (LDH1 and LDH2 must be on same specimen.)

Value* Range Set


55. Total CK (CPK) a. b.


CK-MB (hrt frac) c. . d.


Total LDH e. f.


LDH1 g. . h.


LDH2 i. . j.


LDH1/LDH2 k. . . l.


Troponin I m. . . n.


Troponin T o. . . p.


Value* Range Set


56. Total CK (CPK) a. b.


CK-MB (hrt frac) c. . d.


Total LDH e. f.


LDH1 g. . h.


LDH2 i. . j.


LDH1/LDH2 k. . . l.


Troponin I m. . . n.


Troponin T o. . . p.



*Special Values:

CK-MB, Troponin I, Troponin T

A = Negative or absent or normal

B = Weak positive or weak present or trace or high-normal or small

C = Present or positive or abnormal or medium or large


LDH1/LDH2

D = LDH1/LDH2 reported only as > upper limit or positive or LDH1 > LDH2 (or "flipped")

E = LDH1/LDH2 reported only as < upper limit or negative or LDH1 < LDH2 (or "non-flipped)


56.aa Was BNP measured? Yes No

Y N

Go to Q56af.


56.ab. Record the value of the first, last, and highest measurements of BNP (pg/ml):


1. First: . . 2. date: (mm/dd/yyyy)

3. Last (if more than one): . . 4. date: (mm/dd/yyyy)

5. Highest of remaining . 6. date: (mm/dd/yyyy)

values (if more than two):



56.af Was pro- BNP measured? Yes No

Y N

Go to Q56ac.


56.ag. Record the value of the first, last, and highest measurements of pro-BNP (pg/ml):


1. First: . . 2. date: (mm/dd/yyyy)

3. Last (if more than one): . 4. date: (mm/dd/yyyy)

5. Highest of remaining . 6. date: (mm/dd/yyyy)

values (if more than two):






56.ac. Was serum creatinine measured? Yes No

Y N.

Go to question 56.ae.

56.ad. Record the value of the first, second, and last measurements of serum creatinine (mg/dl):

1: First: . 2. date: (mm/dd/yyyy)


3: Second: . 4. date: (mm/dd/yyyy)


5 : Last: . 6. date: (mm/dd/yyyy)



56.ae. Is this patient currently on kidney dialysis (anytime in the last four weeks)? YES Y

NO N







C. ECG CODING


57. Were any 12 lead ECGs taken

during this admission? ............... Yes Y


No N

Go to Item 97.



58. Are any of the ECGs codable: .......... Yes Y


No N

Go to Item 97.



FIRST CODABLE ECG AFTER ARRIVAL AT HOSPITAL (ECGF)

59. Date of ECGF:

Month Day Year

[Check calibration mark]

a. Time of ECGF:

H H M M



70. Are there other codable ECGs? ......... Yes Y


No N

Go to Item 94.


LAST CODABLE ECG ON THIS ADMISSION (ECGL)


71. Date of ECGL:

Month Day Year


a. Time of ECGL:

H H M M


82. Are there other codable ECGs taken

on or after day 3 after admission,

or on or after day 3 following

an in-hospital event? ................ Yes Y


No N

Go to Item 94.

Find the last codable ECG on day 3 after

admission, or on day 3 after an in-hospital

event (ECGT). [If day 3 ECG is not available,

use first available ECG thereafter.]



THIRD DAY ECG (ECGT)

83. Date of ECGT:

Month Day Year


a. Time of ECGT:

H H M M





94. Were ECGs sent to

Minnesota ECG Reading Center? ..... Yes Y

Go to Item 97. No N


Yes No


a. ECGF sent? .............. Y N


b. ECGL sent? .............. Y N


c. ECGT sent? .............. Y N

D. ADMINISTRATIVE INFORMATION



97. Abstractor number:


98. Date abstract

completed:

Month Day Year




16

File Typeapplication/msword
File TitleARIC HOSPITAL ABSTRACTION FORM
AuthorCSCC
Last Modified Bypandeym
File Modified2009-12-15
File Created2009-11-12

© 2024 OMB.report | Privacy Policy